General Trip Application - Ann Prepare Lavni

Person Info

Name*

As it appears on your passport

First Middle Last

Phone*

Email*

Gender*

Date of Birth*

T- Shirt Size*

Travel Info

Passport Number*

Passport Issued Date*

Passport Expiration Date*

Passport Issuing Country*

Country

Nationality*

Passport Image*

Please upload a clear, readable photo page of your passport page.

Max. file size: 128 MB.

Primary Emergency Contact

Emergency Contact Name*

First Last

Relationship*

Phone Number*

Email*

Secondary Emergency Contact

Emergency Contact Name*

First Last

Relationship*

Phone Number*

Email*

Additional Information

Health Concerns

Dietary Restrictions

Allergies

Medications

Other Considerations

Questionnaire

Where did you hear about Ann Prepare Lavni?

Please list the specific person or organization

Have you traveled outside the continental U.S. before?

If so, when/where?

Why are you interested in going on this trip?

Please list your personal skills, gifts, talents and abilities.

Do you sing, dance, build, teach, have medical skills?

Are you able to endure the high temperatures in Haiti/Dominican Republic?

Please note if you have ever had heat stroke or any issues from being in hot temperatures.

Additional Information

Social Media Accounts URLS (Twitter, Instagram, Facebook)

So we can share/tag you with your permission

Do you currently sponsor a child through ANN PREPARE LAVNI?*

If you intend to sponsor a child and would like to meet them on this trip, we encourage you to sign up for sponsorship as far in advance as possible, so that the child can be in the program before you travel to Haiti/Dominican Republic

Yes

No

Agreements

I will keep ANN PREPARE LAVNI updated through Managed Missions and email of any changes in MEDICAL CONDITIONS, MEDICATIONS, ADDRESS, PHONE #, EMAIL ADDRESS, PASSPORT INFO. etc. This is especially important to provide ALL medical conditions you have and medications/dosages you take. Our Medical Staff and Trip Leaders need this in case you need Medical Treatment when traveling with us. Please keep this updated.

I agree

I will submit all funds to ANN PREPARE LAVNI as required and on schedule

I agree

If for some reason I cannot keep my commitment to this trip I recognize I am still responsible for my flight and any other trip finances that I owe the team

I agree

If there is a weather-related delay while traveling and the airline does not cover expenses I will be responsible for any extra costs involved such as hotel, food and transportation

I agree

I recognize that my deposit is non-transferrable and non-refundable

I agree

I will read, sign and send (email, snail mail, fax) my personal Covenant, Waiver and Release, and Team Contract to ANN PREPARE LAVNI

I agree

I will submit to the leadership of ANN PREPARE LAVNI before and during my trip to Haiti/Dominican Republic for safety and unity of myself and the team

I agree